Scenario #6: Mexican Immigrant, Senor Hernan Riojas-Cortez
Learner Group:PT,SLP, (Dentist, Pharmacist andMD by phone, can be learners or confederates)
Environment: Home Care
Authors: Karen Panzarella
- On-site twoHCPs to jointly prioritize patient care issues
- Identify contributing factors to current change in patient status; fever, limited mobility, elevated blood sugar, skin breakdown
- Identify and understand cultural barriers that could influence patient compliance and plan for care
- UseSBAR communication for exchange of all pertinent patient care amongHCPs (physician, dentist, pharmacist)
|1||T||PT/SLP review previous home care visit notes for baseline information and standing orders|
|2||T||PT/SLP initiate focused assessment to include: interview with wife and patient, vital signs, heart sounds, lung sounds and respiratory effort,O2 sat, and oral cavity screen|
|3||T||PT/SLP initiate secondary assessment to include: pain, skin integrity, last bowel movement, urine output and character, ability to chew and swallow, intake of fluids and food, mobility and identify changes since last evaluation byHCP|
|4||C||PT/SLP reviews medication schedule and compliance status|
|5||B||PT/SLP contact Dentist for history and useSBAR to communicate assessment|
|6||C||Dentist to determine when or if patient needs to be seen in the office or ER|
|7||B||PT/SLP contact Pharmacist for medication reconciliation and useSBAR to communicate assessment|
|8||B||PT/SLP contactMD and useSBAR to communicate current status and possible new orders|
|9||C||PT/SLP to create a plan for medication management|
|10||B||PT/SLP to identify resources and create a plan to ensure patient has follow-up visits|
|11||T||PT/SLP documents patient assessment, status, change, interventions, plan, critical conversations and outcomes|
- SBAR communication tool
- Situational Awareness/Cultural considerations
- Prioritization following primary and secondary assessment
- Accessing Resources
- Decision Making
- Wife/caregiver talks for patient and gives conflicting information, speaks primarily Spanish with limited English
- Patient speaks primarily Spanish with very limited English
Patient portraying "machismo" and noncompliant with meds
- PT last saw patient last week, was progressing well
- SLP has just taken over this patient case from previousSLP
- HCPs unaware patient had dental surgery - wife went ahead with scheduled extraction since it took 7 weeks to get the appointment
- Multiple current and non-current dose medications in a jumble in a basket on the counter - daily pill count box is "lost" somewhere", patient refuses to take medication
Synopsis of scenario
72 year old Hispanic male who is being visited byPT andSLP at a joint home healthcare visit. Patient was discharged from the hospital (inpatient x 1 week) four weeks ago after a mild stroke (left brain with right sided weakness with swallowing and speech issues).
The patient had oral surgery (unrelated to hospital course) 5 days ago. An apparent infection has ensued and the patient has eaten very little food, drank very little fluids, and has not taken all his medications. He also has had decreased mobility for 2 days (he can ambulate to the bathroom, but prefers to stay in his bed).
Today's date is the 10th of the month.
- Dentist- by phone (can be confederate)
- Pharmacist - by phone (can be confederate)
- MD- by phone (can be confederate)
Confederate roles and scripting
|Role||Tone||Timing of participation||Lines / Comments|
Speaks limited English, Spanish is primary language
Gives conflicting information
|Onset of scenario||
I just did his blood sugar and hour ago and it was 320.
He can take his little pills but not those big ones you know. It's too hard for him to swallow. He keeps telling me he doesn't want to take the medicine, he is being macho.
Theres just too many pills to keep track of. That's why I keep them all here in this basket.
|Complains about husband unwilling to take medication and did not want to call anyone for help other than family members||Throughout scenario||
I don't want to throw away the old ones cause they are all so expensive and what if he needs them again?
He's been up a lot until the past few days. He's been in bed for 2 days now. Won't even get up to eat. Just lays there and sleeps. Won't even drink a ginger ale.
We went to the oral surgeon because it was scheduled before his stroke. Just about put me under getting him there and back. I am plumb worn out from taking care of him.
Name: Senor Hernan Riojas-Cortez
Weight: 195 lbs
Religion: Roman Catholic
Past medical history
Chronic recurring kidney infections. Diabetes x 3 years controlled with Metformin and diet.
History of present illness
Mild stroke 4 weeks ago with residual right sided weakness, slurred speech, and some difficulty swallowing. Did well withPT at home 2x week for 3 weeks after discharge.PT is now just weekly. Has weeklySLP visits for speech and swallowing. Home health aide comes 2x week to help with bathing and personal care, but wife many of times refuses the help.
Retired from the railroad. Active in community events and belongs to an Elk's club.
Report to participants
Today's date: 10th day of the month.
SLP: "you are a covering for vacation for the regularSLP that has been working with Senor Cortex for the past 3 weeks in home care. You know that the patient had a (L)CVA and has speech and swallowing difficulties.
PT: "you have been treating this patient twice a week for the past 3 weeks in his home; he has been progressing with ambulation with a quad cane for 80 feet with supervision x 1. You are working on functional mobility and patient/family education."
|Staged for learners||Available for learners to use|
Laying in bed; head up (multiple pillows)
Foul odor coming from mouth
Infected tooth extraction area
Skin turgor indicates dehydration
Patient has slightly slurred speech and speaks primarily Spanish, which is stable from previous history
(R) sided weakness arm, leg
Patients home in bedroom
Loud TV or radio turned on
Multiple rumpled throw rugs on floor
Multiple TV and electrical cords easily pulled or tripped over
Quad Cane at bedside
Commode at bedside and Urinal
|Glucometer - results 340|
Will have to create med intake discrepancy in pill bottles to match Pharmacist, Dentist andMD discussions; assuming that today's date is October 10th.
Warfarin 2mg po daily
EC-ASA 81mg po daily
Simvastatin 20mg po nightly
Lisinopril 10mg po daily
Metformin/glyburide 500/5mg 2tabs po twice daily
Amoxil 500mg 1 capsule three times a day for 7 days
|Additional other outdated medications in old bottles in a basket: Expired Metformin ER, Lipitor 40mg, Glucosamine/Chondrointin, Chromium,MTV, Warfarin 1mg, Cinnamon, TylenolPM, Pericolace, Tums, Ex-lax.|
Home Health Care Notes from last 2 visits
Home Health Care Notes and Orders blank for this visit documention
Pharmacy medication records
MD history, physical, and plan of care as of 2 weeks ago
Progression of events
|Manikin Actions||Performance Measures||Cues
Confederates In and Out
Script: "I have pain in my mouth, it hurts when I swallow"
Other: Speech is slightly slurred from stroke, English is broken, some Spanish words
Wife keeps interrupting with conflicting information see script
Wife states that her husband is being macho and doesn't want to take the medicine
trend over minutes
Tone: slightly agitated
Script: "She won't listen to me, She never listens." " I am the Man, I do not want to take pills" "puedo tomar el dolor, no quiero las pastillas" (I can take the pain, I don't want the pills)
10- 20 minutes
trend over minutes
Integrated debriefing guide
|Threads||Performance Measures||Debriefing Prompt|
Give us a quick summary of what happened.
What went well?
What didn't go so well?
|Understand clinical presentation||Dentist to determine when or if patient needs to be seen in the office||
What signs and symptoms would you expect for this type of patient?
What signs and symptoms were present?
How did the patient describe his/her symptoms?
What other presentations can produce similar symptoms?
|Identify contributing factors||
What co-morbidities were present?
What risk factors were present?
|Recognize a change in patient status||
What was concerning at this point?
What was the call for help based on?
|Identify correct intervention / treatment||
What is the accepted standard of care for this type of patient?
How was it used?
What other options for care would be reasonable?
What other clinical resources could be accessed?
|Understand cultural implications||
What cultural influences may be present?
Are there any inherent risk factors for this population?
What does "machismo" have to do with the patient refusing medication? How does antibiotics differ from pain meds in this decision?
PT/SLP initiate rapid focused assessment to include: vital signs, heart sounds, lung sounds and respiratory effort,O2 sat, andFSBS
PT/SLP initiate secondary assessment to include: pain, skin integrity, last bowel movement, urine output and character, oral cavity, ability to chew and swallow, intake of fluids and food, mobility, identify changes since last evaluation byHCP
|What specific assessments are important to consider with this type of patient?|
|Infection Control||What kinds of infection control practices occurred? What should occur?|
|Medication Administration||PT/SLP reviews medication schedule and compliance status||What types of drugs should be considered for this type of patient? How can we make sure the right medication gets to the right patient?|
|Patient Safety||Describe factors that create a "culture of safety". Describe "work arounds" required to care for this patient.|
PT/SLP review previous home care visit notes for baseline information and standing orders
PT/RN documents patient assessment, status, change, interventions, plan, critical conversations and outcomes
What is important to document?
How can we manage documentation during a critical event?
PT/SLP contact Dentist for history and useSBAR to communicate assessment
PT/SLP contact Pharmacist for medication reconciliation and useSBAR to communicate assessment
PT/SLP contactMD and useSBAR to communicate current status and possible new orders
What thoughts do we have about this exchange?
What additional information would be helpful?
What are some ways we could improve on sharing information?
How can we advocate for specific action when team members are uncooperative?
What information is most important when transferring patient care?
|Situational Awareness||Cultural Considerations||
How might the concept of Machismo conflict with a rehab program? How might it enhance a rehab program?
Were the big picture or task focused?
What are strategies for keeping the big picture in view?
|Decision Making Prioritization||
PT/SLP to create a plan for medication management
PT/SLP to identify resources and create a plan to ensure patient has follow-up
What information was necessary to make a decision? What cultural considerations need to be explored?
How were decisions made?
What resources could be accessed?
When was there a clear leader?
Did everyone know their role?
How were the roles delegated?
How could the workload be divided up differently?
|Professional Behavior||To patient, family, otherHCPs||
How were we coming across?
What was the team performance like?
What would happen if the "regular" team was not present? What are some strategies for managing difficult interactions?
What was the conflict and how was it managed?
What would we do differently next time?
Any other questions or comments?